Provider Demographics
NPI:1497724413
Name:TILGNER, THERON C (DO)
Entity Type:Individual
Prefix:DR
First Name:THERON
Middle Name:C
Last Name:TILGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 LAKE HAVASU AVE S STE 108
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6526
Mailing Address - Country:US
Mailing Address - Phone:928-854-3333
Mailing Address - Fax:928-854-3335
Practice Address - Street 1:297 LAKE HAVASU AVE S STE 108
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6526
Practice Address - Country:US
Practice Address - Phone:928-854-3333
Practice Address - Fax:928-854-3335
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3501207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ496324Medicaid
AZZ108124Medicare PIN
G99490Medicare UPIN
AZZP00289080Medicare PIN